Obstetric

Question 1

What is acute fatty liver of pregnancy?

Answer 1

Acute fatty liver of pregnancy is a rare but serious condition of the 3rd trimester characterised by progressive lipid accumulation in hepatocytes leading to liver dysfunction and multiorgan failure

Question 2

Describe management of acute fatty liver of pregnancy?

Answer 2

Specific vs Supportive

Specific
Expedited delivery

= Regional anaesthesia contraindicated generally due to coagulopathy
= High foetal mortality and liver/renal failure may worsen in 48hrs following delivery

Supportive
- IV access
- Careful IV fluid resuscitation (risk of peripartum cardiomyopathy and ARDS
- IV glucose if hypoglycaemic
- Correction of coagulopathy with blood products
- Intubation/vent if ARDS
- RRT

Question 3

Differentials for maternal collapse?

Answer 3

Haemorrhagic
- Postpartum
- Antepartum (p. praevia/accreta, p. abruption, uterine rupture, ectopic)

Thromboembolic
- PE
- Amniotic F.E

Cardiac disease
- Myocardial infarction
- Cardiomyopathy
- Valve lesions
- Arrythmias

Neuro:
- Eclamptic fit
- SAH

Regional anaesthesia related:
- High block (high spinal)
- LAST

Immunological:
- Sepsis
- Anaphylaxis

Question 4

Pathophysiology of AFE?

Answer 4

Amniotic fluid enters maternal circulation via ruptured uterine/cervical veins

Thought to be likely IMMUNE mediated rather than embolic

Phase 1
- Mast cell degranulation to foetal antigents, biochemical mediators
- PA vasospasm –> P. hypertension –> RV dysfunction,
- Hypoxaemia and hypotension

Phase 2
- LV failure and pulmonary oedema
- Endothelial activation and leakage
- DIC and uterine atony

Question 5

Features of AFE?

Answer 5

Maternal cardiac arrest and neonatal distress

Cardiac - profound hypotension, collapse, arrhythmia
Resp - breathlessness, cyanosis
Haem - DIC

Question 6

Risk factors of AFE?

Answer 6

Strong:
- Induction of L
- Oxytocin use
- Instrumental/c. section

Moderate
- Advanced mat. age
- Male foetus
- Multiple preg.
- Abruption
- IUFD

Question 7

Management principles of AFE?

Answer 7

ABCDE assessment and mx.
Aim is to maintain organ perfusion and oxygenation
May include:
I+V, high FiO2
L Lat tilt (antepartum)
Peri-mortem C.section
Haemorrhage mx

Supportive therapies
- ECMO
- TEG
- PA catheter
- IABP
- Pulm vasodilators

Question 8

Patient factors - maternal sepsis

Answer 8

Obesity
Diabetes
Immunosuppression
Low socioeconomic class
Black or Asian ethnicity
History of PID

Question 9

Obstetric factors - maternal sepsis

Answer 9

Amniocentesis/cervical suture

Prolonged rupture of membranes
Prolonged trauma with repeated VEs
Vaginal trauma
Episiotomy
C. Section
Retained products

Question 10

Causes of antepartum haemorrhage?

Answer 10

Placenta praevia (33%)
- Placenta encroaches or covers cervical os

Placental abruption (33%)
- Abnormal separation of placenta from uterus
- May have retroperitoneal clot

Uterine rupture

Question 11

What is placenta accreta ?

Answer 11

Placenta attaches to myometrium (not just endometrium)

Question 12

What is placenta increta?

Answer 12

Placenta invades into the myometrium

Question 13

What is placenta percreta?

Answer 13

Placenta invades through the perimetrium

Question 14

Mx of p. accreta spectrum

Answer 14

Screening those with risk factors to identify antenatally
- P. praevia with prev. scar
- Increased maternal age
- Multiparity

MDT planning, deliver at tertiary centre 34-36 weeks
Prompt resuscitation and mx postpartum haemorrhage

Neuraxial is ok

X-match preparation of blood

Access to TEG

IR availability
Balloon occlusion of internal iliac arteries

Question 15

Classification of p. praevia

Answer 15

Complete vs. partial. vs. margina (marginal = placenta >2cm from os) - suitable for vaginal delivery